AMT Practitioner Membership Application Form

Transcription

1 Association of Massage Therapists Ltd PO Box 826 Broadway NSW 2007 T: F: ABN AMT Practitioner Membership Application Form APPLICATION CHECKLIST Have you: attached a passport photo? attached a copy of your massage qualification and academic transcript? attached a copy of your HLTFA301B First Aid certificate? supplied the names and contact details of three character referees? signed the form? attached your cheque/money order or completed your credit card details? attached proof of membership of another association if transferring membership? We cannot accept applications via fax. Please post your original to: AMT Ltd PO Box 826 Broadway NSW 2007 or it to [email protected] PRIVACY STATEMENT The Association of Massage Therapists Ltd is subject to the provisions of the Privacy Act Any personal information you supply to us on membership application forms or any changes to your details is used strictly in accordance with the Act and kept in the strictest confidence. You have the right to access and correct any personal information that the Association holds about you. None of the details given by you will be divulged to third parties without your permission and knowledge. Your personal information may be used only by this Association to improve our services and to provide you with the latest information about any new related services and promotions such as workshops, conferences and membership reminders. PLEASE NOTE: Your membership application will usually be processed within two weeks of receipt of all documentation at AMT Head Office and you will be notified of the result in writing. Please supply all requested documentation. An incomplete application will cause delays in processing your membership.

2 AMT PRACTITIONER MEMBERSHIP APPLICATION FORM PLEASE COMPLETE ALL PAGES AND PRINT CLEARLY ALL QUESTIONS MARKED WITH A * MUST BE COMPLETED * I am applying for General level Senior level 1 Senior level 2 I am upgrading from student membership or I have previously been a member and would like to rejoin AMT or I am transferring from another association. If so, which association? OFFICE USE ONLY Date Received: Date Approved: Member number: NB Proof of membership with the other association is required * How did you hear about AMT? * Why did you choose AMT? PROBITY * Have you ever been a member of another professional association? YES NO * If yes, have you ever been expelled or sanctioned from that association? YES NO * Have you been the subject of any disciplinary, legal or criminal proceedings? YES NO * Are you aware of any pending disciplinary, legal or criminal proceedings? YES NO PERSONAL DETAILS * First name: * Surname: * Date of birth: Male: Female: * Mailing address: Please attach passport photo here * State: * Post code: CONTACT NUMBERS: * Home: * Work: * Mobile: * address: PRACTICE ADDRESS AND REFERRAL DETAILS Your practice address is required for health funds and will be forwarded to all relevant funds. (Please put your street address, a post office box is not acceptable) Practice Address 1: State: Post code: Phone Number(s): Referrals for this address: YES NO Practice Address 2: State: Post code: Phone Number(s): Referrals for this address: YES NO If you have more practice addresses, please supply all relevant details on a separate sheet of paper and indicate whether you would like referrals for each practice address. * BULLETIN * I wish to receive my AMT quarterly journal by NO YES (If you tick this option you will not receive a hard copy)

3 AMT PRACTITIONER MEMBERSHIP APPLICATION FORM AMT WEBSITE FIND A THERAPIST To have you details listed on the website the following information is required Referral Suburb: Postcode: Referral Phone number: (at the moment only one suburb can be recorded) I specialise in the following: I do home visits: YES NO I do hospital visits: YES NO I do not wish to have my name, practice suburb(s), contact number and specialties listed on the AMT website: NB: You must be a participant in the CEU scheme to be listed on the website * DETAILS OF QUALIFICATIONS * Name of school: * Name of qualification: * Year of Graduation: * Please attach certified copies of all certificates/diplomas held and academic transcripts showing subjects completed. * CONTINUING EDUCATION * I confirm I would like to be included in the CEU scheme: YES NO AMT encourages all members to participate in our CEU scheme. When you maintain your CEU status you are eligible for website referrals. It is a legal requirement to do continuing education to be able to be recognised as a provider with Private Health Funds PROFESSIONAL INDEMNITY INSURANCE I wish to have insurance information sent to me. (If you tick yes, we will arrange to have insurance policy information sent to you when your membership is approved). YES NO * REFEREES List three (3) character referees (name and telephone number) from persons other than family who have known you for the last two years: * 1. Name: Telephone number: * 2. Name: Telephone number: * 3 Name: Telephone number: * DECLARATION AND AGREEMENT I declare that the information given on this form is true and correct. I understand that: I must pay all my subscriptions and other monies due until I resign my membership I declare that I will abide by the AMT Code of Ethics and any applicable rules, codes and regulations I declare that I will abide by all applicable health fund provider terms and conditions * Signature: * Date: PAYMENT DETAILS: * YOUR APPLICATION WILL NOT PROCEED WITHOUT YOUR APPLICATION FEE. PLEASE NOTE AMT DOES NOT ACCEPT THIRD PARTY PAYMENTS. You may choose to send the annual membership fee with your application form or wait for our notification. I have attached my cheque/money order in the amount of please debit my Visa/Mastercard in the amount of Cardholder s Name: Signature of Cardholder: $ $ OR (Refer to Schedule of Fees) Card number: Expiry date:

4 MEMBERSHIP ELIGIBILITY AND FEES FOR 2016 AMT has three practitioner levels of membership. GENERAL LEVEL AMT recognises the following qualifications at General Level: HLT40302/07/12/HLT42015 Certificate IV in Massage HLT40102 Certificate IV in Traditional Chinese Medicine Remedial Massage HLT40202 Certificate IV in Shiatsu SENIOR LEVEL ONE AMT recognises the following qualifications at Senior Level One: HLT50302/07/HLT52015 Diploma of Remedial Massage HLT50102/07/12/HLT52115 Diploma of Traditional Chinese Medicine Remedial Massage HLT50202/07/12/HLT52215 Diploma of Shiatsu SENIOR LEVEL TWO AMT recognises the following qualifications at Senior Level Two: NSW TAFE Associate Diploma of Health Science (Massage Therapy) NSW TAFE Diploma of Health Science (Massage Therapy) CIT Advanced Diploma of Applied Science in Remedial Massage CIT Advanced Diploma of Soft Tissue Therapies Advanced Diploma of Remedial Massage (Myotherapy) FEE SCHEDULE Membership costs (includes 10% GST) Level of membership Application fee* Annual fee Total cost for new members General Level $75.00 $ $ Senior Level One $75.00 $ $ Senior Level Two $75.00 $ $ *This is a non-refundable fee, which must be sent with your Application Form

5 INSURANCE SCHEDULE OF FEES Aon Risk Services Australia Limited offer a claims made policy. This policy covers you for claims, or circumstances which may give rise to a claim, reported to the Insurers while the policy is in force. Once the policy has expired you are not covered except for claims and circumstances notified to the insurers before the policy has expired. If you cease to practice, however want to continue to be covered for past work, then you will need to purchase Run Off cover. Please note Aon does offer free Run Off cover for retired sole practitioners as long as the practitioner does not return to practice. This is subject to the practitioner advising Aon of their retirement. Arthur J. Gallagher offers a policy which is on an occurrence basis, i.e. any incidents which occur whilst you are/were insured (even if the claim is made several years after you cease paying premiums) are covered. Fenton Green & Co offer a combined professional indemnity and public & products Liability insurance policy for massage therapists. The policy is underwritten by Guild Insurance. The cost of basic insurance (inclusive of GST) through AMT in 2016 is: Amount covered Aon Risk Services Australia Limited Arthur J. Gallagher Fenton Green & Co $1,000,000 $ $ $ $ $2,000,000 $ $ $ $ $5,000,000 $ $ $ $ AMT strongly recommends coverage of at least $1,000,000 required for health funds